Standard Operating Procedure Documents - Leslie Dan … · · 2014-01-30Standard Operating...

Leslie Dan Faculty of Pharmacy • University of Toronto • 144 College Street, Toronto, Ontario, Canada M5S 3M2 • Tel:

416-978-2889 • Fax: 416-978-8511

of 1

Standard Operating

Procedure Documents

Leslie Dan Faculty of Pharmacy, University of Toronto

These Standard Operating Procedures (SOPs) are controlled documents. They are authored and

maintained by the Joint Health and Safety Committee (JHSC) at the Leslie Dan Faculty of

Pharmacy, University of Toronto.

All information contained in these documents is the property of the Leslie Dan Faculty of

Pharmacy, University of Toronto.

Standard Operating Procedure – Master Listing Document

Last Updated: 29-Jan-14


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SOP - Master Listing Page 1 of 1

Standard Operating Procedure – Master Listing

SOP # SOP Title Rev # Approval

Date

Filename

PBSOP001 Standard Operating Procedure

Management

0 22-Mar-12 PBSOP001 Rev 0.pdf

PBSOP002 Solvent and Chemical Storage,

Transport, and Disposal

2 29-Jan-14 PBSOP002 Rev 2.pdf

PBSOP003 Emergency Response and First Aid 1 11-Sep-12 PBSOP003 Rev 1.pdf

PBSOP004 Autoclaving Procedures 0 22-Mar-12 PBSOP004 Rev 0.pdf

PBSOP005 Cryogenics 0 22-Mar-12 PBSOP005 Rev 0.pdf

PBSOP006 Radioactive Material Handling and

Disposal


PBSOP007 Biohazardous Material Handling and

Disposal


PBSOP008 Electrical Safety 0 22-Mar-12 PBSOP008 Rev 0.pdf

PBSOP009 Laboratory Health and Safety

Inspections


PBSOP010 Emergency Procedures – Mercury

Spills

0 29-Jan-14 PBSOP010 Rev 0.pdf

~, lI!? ; UNIVERSITY OF TORONTO~ LESLIE DAN FACULTY or- PHARMACY

Standard Operating Procedure DocumentTitle: Standard Operating Procedure Management

SOP#: PBSOPOOl I Rev#: 10

Standard Operating ProcedureTitle: Standard Operating Procedure ManagementIssue Date: 'IOoorwcn ,",.111'"' 1'1 H fif...lI:.

SOP#: PBSOPOOl ." , .~ •...u • If. \ •.•. t: ~I!Jf!

Revision #: 0

This is a controlled document, authored and maintained by the Joint Health and SafetyCommittee (JHSC)at the Leslie Dan Faculty of Pharmacy, University of Toronto.

All information contained in this document is the property of the Leslie Dan Faculty ofPharmacy, University of Toronto.

~o-M.v-- la....Author of this Revision:David Dubins, Ph.D., B.Eng.Me~2n:tYcomm;ttee

Date

Reviewed by:Zarko ZlicicFaculty TechnicianMember, Joint Health and Safety Committee

Date

filiJ jJ O'~Approved by:Peter J. O'Brien, Ph.D.Professor EmeritusChair, Joint Health and Safety Committee

Date

'Lt- ~ MJ2.A£k <- ,2-DateAuthorized 'by:

Henry J. Mann, Pharm.D., FCCP,FCCM, FASHPDean and Professor

Leslie Dan Faculty of Pharmacy. University of Toronto. 144 College Street, Toronto, Ontario, Canada MSS 3M2. Tel:416·978-2889 • Fax: 416-978-8511

PBSOP001 Rev O.docx Page 1 of 6

Standard Operating Procedure Document

Title: Standard Operating Procedure Management

SOP #: PBSOP001 Rev #: 0


416-978-2889 • Fax: 416-978-8511

PBSOP001 Rev 0.docx Page 2 of 6

1. Scope

This specific SOP will describe procedures for the creation, maintenance, revision, distribution, and

termination of JHSC SOPs in the Leslie Dan Faculty of Pharmacy. This series of SOPs specifically

pertain to the health and safety of all students (undergraduate and graduate), faculty, staff, and

visitors, unless otherwise specifically indicated. This system of SOPs is intended to provide

building-specific guidelines concerning the policies outlined by the University of Toronto Office of

Environmental Health and Safety (OEHS).

2. Objective

The objective of this SOP is define a structure and process for SOP document management. This

includes authorship and signing authority for SOP creation, review, approval, authorization, and

termination of JHSC SOPs.

3. Background

The Leslie Dan Faculty of Pharmacy is an organization committed to protecting and monitoring the

health and safety of people in the building. The Joint Health and Safety Committee is the body

responsible for overseeing this important task and reporting to the OEHS. SOPs are now required

by the OEHS. This series of SOPs are compliant with this requirement.

4. Definitions and Abbreviations

A Standard Operating Procedure, or SOP, is defined as a document that outlines a specific

procedure or set of procedures to be followed in carrying out a given operation or a given

situation. An SOP provides enough detail so that a novice can identify the proper person or people

who should be involved in carrying out the procedure, and after having read the SOP this person

would have enough information to either carry out the task properly, provided the instructions are

followed, or be referred to the appropriate resources (working documents, workshops, or

designated people) so that the task would be carried out properly. An SOP is distinct from a

working document or scientific protocol in that it is a controlled document, has revision tracking,

with a review and authorization procedure pre-defined. In other words, creation, modification,

and termination of the document follow an explicitly defined, monitored, and documented

checkpoint process, with an audit trail. SOPs are ubiquitous across many industries, and are

present in academia as well.

Abbreviations used in this document are defined in this section:

SOP Standard Operating Procedure

JHSC Joint Health and Safety Committee of the Leslie Dan Faculty of Pharmacy, at





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the University of Toronto

OEHS Office of Environmental Health and Safety, University of Toronto

TBD To be determined

N/A Not Applicable

Rev. Revision

5. Policies

1. The University of Toronto, as an employer, is responsible under the Ontario Occupational

Health and Safety Act for establishing and maintaining joint health and safety committees

in the workplace. SOPs controlled by the JHSC shall be limited to matters pertaining to the

jurisdiction and scope of this committee.

2. Any member of the JHSC may create or revise an SOP.

3. References to authorship, review, approval, and authorization contained in the Policies or

Procedures section of an SOP should refer to the involved person’s job title, not their

name.

4. Any disagreement regarding SOP related procedures or policies may be addressed and

decided upon at JHSC meetings.

5. The original, signed hard copies of the most recent SOPs will be kept in an SOP library

within the building, and an electronic (scanned) library will be maintained on the JHSC

website.

6. An SOP can refer to other documents (e.g. working documents and protocols) to guide the

reader to external policies and procedures.

6. Procedures

6.1.1 SOP Creation

1. The SOP template (PBSOP0xx Rev 0 (Draft) - Template.docx) should be used to create

SOPs.

2. The SOP number will be in the format “PBSOP0xx”, where “xx” is a currently un-used

number.

3. The revision number of an SOP corresponds to the number of revisions of approved

versions that have been made. The revision number of a draft document will be labeled “0

(Draft)”. The first approved SOP version revision number will be 0. Subsequent revisions

will increment the revision number by 1.

4. Once an SOP is written in draft form, it is circulated to members of the JHSC for

comments. This can be in the form of a hard copy or email.

5. Members of the JHSC are to read the draft SOP and provide optional comments to the

revision author within a reasonable time frame.

6. Comments are received by the revision author and incorporated.





416-978-2889 • Fax: 416-978-8511


7. Once comments are incorporated, the SOP is reviewed by the Faculty Technician, the JHSC

Chair, and the Dean of the Faculty of Pharmacy.

8. Any comments by the Faculty Technician, JHSC Chair, and Dean of the Faculty, are

addressed and incorporated into the SOP by the revision author.

9. Once all comments have been addressed, the revision number will be updated to “1”

10. The SOP is printed out for signing.

11. The signatory page will be signed by the revision author, Faculty Technician, JHCS Chair,

and Dean of the Faculty. The roles of each party will be:

Signatory Role

Any JHSC Member Revision Author

Faculty Technician Reviewer

JHSC Chair Approval

Dean of the Faculty Authorization

12. Once signed by all signatories, the SOP is considered finalized.

13. The signed hard copy of the SOP is to be included into the SOP library.

14. The signed SOP is scanned and included in the online SOP library in PDF format.

15. A notice is sent out to the Faculty that a new revision of the SOP is accessible on the JHSC

website.

16. The master list of SOPs is updated to include the new SOP.

6.1.2 SOP Revision

1. The most recently approved word processor version of the SOP to be revised should be

obtained from the previous revision author of the SOP.

2. The revision author will add their name to the signatory page of the SOP. The SOP will be

revised in such a way as to make clear the changes made (e.g. using the “track changes”

feature in Microsoft Word) or by using strikeout and alternate formatting.

3. The revision number of the draft document will be increased and followed with “(Draft)”.

E.g. the revision number of the first revision of an SOP will be “1 (Draft)”.

4. Once an SOP is revised in draft form, it is circulated to members of the JHSC for

comments. This can be in the form of a hard copy or email.

5. Members of the JHSC are to read the draft SOP and provide optional comments to the

revision author within a reasonable time frame.

6. Comments are received by the revision author and incorporated.

7. Agreed upon changes that are made to the SOP are detailed in the “Revision History”

section of the SOP. Sufficient details are provided regarding changes of the SOP, to enable

the reader to understand what changes were made, and which sections of the SOP were

amended.

8. Once all comments have been addressed, “(Draft)” will be removed from the revision

number.

9. The SOP is printed out for signing.





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10. The SOP is reviewed by the Faculty Technician, the JHSC Chair, and the Dean of the Faculty

of Pharmacy. Any comments arising by the Faculty Technician, JHSC Chair, and Dean of the

Faculty, are addressed and incorporated into the SOP by the revision author. Revisions at

this stage are not expected to be significant or impactful, as the committee (including the

JHSC Chair) will have already have reviewed the document in Draft form and provided

comments. Signing may occur during this step.

11. The signatory page is then signed by the revision author, Faculty Technician, JHCS Chair,

and Dean of the Faculty. The roles of each party will be:

Signatory Role

Any JHSC Member Revision Author

Faculty Technician Reviewer

JHSC Chair Approval

Dean of the Faculty Authorization

12. Once signed by all signatories, the SOP is considered finalized.

13. The signed hard copy of the SOP is to be included into the SOP library.

14. The signed SOP is scanned and included in the online SOP library in PDF format.

15. The previous SOP revision is retained in a separate binder for archival purposes.

16. A notice is sent out to the Faculty that a new revision of the SOP is accessible on the JHSC

website.

17. The master list of SOPs is updated to reflect the new revision number of the SOP.

6.1.3 SOP Termination

1. The decision to terminate an SOP should be arrived at by a vote of majority by voting

members of the JHSC.

2. Following a majority vote, the electronic version of the SOP is removed from the SOP

library online.

3. The hard copy of the SOP is retrieved from the SOP library. The word “CANCELLED” and

the effective date are written on the signatory page.

4. The JHSC Chair and Dean will initial on the front page of the hard copy original that the

SOP has been cancelled and removed from the SOP library.

5. A notice is sent out to the Faculty that the SOP has been cancelled, and has been removed

from the JHSC website. The Faculty is informed to recycle any printed out copies they may

have made.

6. The cancelled SOP is retained in a separate binder for archival purposes.

7. The master list of SOPs is updated to reflect removal of the terminated SOP.





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7. Revision History

Revision # Date SOP Section(s) Revision

Description

Revised By

0 20-Mar-12 SOP PBSOP001

created.

David Dubins (revision

author)


Title: Solvent and Chemical Storage, Transport, and

Disposal



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PBSOP002 Rev 2 Page 2 of 6

1. Scope

The scope of this SOP is to provide building-specific details regarding the safe transport, storage,

and disposal of laboratory grade solvents, and solid material in contact with hazardous chemicals,

in the Leslie Dan Faculty of Pharmacy.

This SOP is not intended to replace, supersede, or contravene any of the policies or training

outlined by the Office of Environmental Health and Safety (OEHS), available online via the

following website:

http://www.ehs.utoronto.ca/resources/manindex.htm

The SOP is intended to clarify how site-specific aspects of OEHS policies are dealt with in order to

ensure they are appropriately implemented. OEHS policies will not be re-iterated in this

document, but rather the reader is referred to the link above, to the Policies and Procedures

Listing Health and Safety Manual.

The scope of this SOP does not include radioactive, cryogenic, or biohazardous substances, or

chemical spills pertaining to these materials.

2. Objective

The objective of this SOP is to outline the appropriate training, resources, policies, and the

building-specific procedures pertaining to solvent and chemical storage, transport, and disposal in

the Leslie Dan Faculty of Pharmacy.

The SOP outlines the training students are provided with, as well as the logistics pertaining to

solvent handling (both inorganic and organic), and chemical solid waste disposal.

3. Background



responsible for overseeing this important task and reporting to the OEHS at the University of

Toronto. SOPs are now required by the OEHS. This series of SOPs are compliant with this

requirement.

Proper solvent handling and disposal are an essential aspect of safety, as improper

storage, disposal, and even mislabelling can pose a risk to the public.



Disposal



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4. Definitions and Abbreviations A “solvent” in this document is defined as a liquid intended for laboratory use, for research or

educational use in a laboratory setting.





OEHS Office of Environmental Health and Safety, University of Toronto


N/A Not Applicable

Rev. Revision

5. Policies 5.1.1 Chemical Spill Kits

1. Chemical spill emergency procedures are available on the OEHS website:

http://www.ehs.utoronto.ca/resources/manindex/eps/emrgchm2.htm

2. Safety training for graduate students and research associates is a Faculty requirement, and

occurs twice yearly in the Leslie Dan Faculty of Pharmacy. Chemical spill response is a

component of the safety training course.

3. Standard chemical spill kits are available for purchase through the OEHS.

4. Each research floor (floors 7-12) shall be equipped with its own spill kit, visibly located in a

central place and accessible to everyone on the research floor.

5. Principal Investigators can also opt to stock their individual laboratories with a spill kit and

include the appropriate hazard-specific materials in their laboratory spill kit.

6. Principal Investigators may also adapt or compliment the floor spill kit to comply with the

requirements of their laboratory.

7. Each spill kit shall contain an inventory list of its contents.

8. The inventory list shall be checked on a yearly basis by the Faculty Technician to ensure

that it is complete.

9. In the event that a spill kit is used, the person using the spill kit shall inform the Faculty

Technician so that the kit may be replenished.

5.1.2 Solvent Storage Room

1. Chemical storage guidelines are available on the OEHS website:

http://www.ehs.utoronto.ca/Assets/ehs+Digital+Assets/ehs3/Chemical+Safety/Chemical+

Storage.pdf

2. “Flammable Liquid Storage: Standard for Storage Rooms” guidelines are available on the

OEHS website:

http://www.ehs.utoronto.ca/Assets/ehs+Digital+Assets/ehs3/documents/Flammable+Liq

uids+Storage+RoomsMar2007.pdf



Disposal



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occurs twice yearly in the Leslie Dan Faculty of Pharmacy. Proper solvent storage is a

component of the safety training course.

4. Research laboratories in the Leslie Dan Faculty of Pharmacy are often limited in the

quantities of specific chemicals they are permitted to store in their own laboratory space.

5. The Solvent Storage Room, located on the penthouse floor of 144 College Street, is

designed to safely store chemicals which surpass the permitted storage quantity.

6. The Solvent Storage Room is designed to store only new, unopened solvents and

chemicals only.

7. Access to the Solvent Storage Room is controlled and monitored via electronic FOB.

8. The Solvent Storage Room is protected by a preaction/foam sprinkler system.

9. The isolation valve of the Solvent Storage Room is located on the upper penthouse/north

west corner.

10. The Solvent Storage Room contains separate sections for acids, and flammable solvents.

5.1.3 Solvent and Chemical Waste Room

1. Laboratory Hazardous Waste Management and Disposal Guidelines are available on the

OEHS website:

http://www.ehs.utoronto.ca/resources/wmindex.htm


occurs twice yearly in the Leslie Dan Faculty of Pharmacy. Solvent and chemical waste

disposal is a component of the safety training course.

3. The Solvent and Chemical Waste Room, located on the penthouse floor of 144 College

Street, is designed to safely store chemicals which are intended for disposal.

4. The Solvent and Chemical Waste Room is designed to store only used solvents and

chemicals.

5. Access to the Solvent and Chemical Waste Room is controlled and monitored via

electronic FOB.

6. Radioactive materials are not permitted in the Solvent and Chemical Waste Room.

7. Disposal of solid material in contact with hazardous chemicals may also be placed in the

Solvent and Chemical Waste Room.

6. Procedures

6.1.1 Transport and Storage of Unopened Solvents

1. Solvents should be transported in their original packaging. The unopened bottles should

be appropriately labeled (the product label is sufficient).

2. The unopened bottles should also be affixed with a label indicating which lab the

chemicals belong to. A labeled box may also be used to group chemicals by laboratory.

3. Glass bottles and containers should be transported using one of the following two

methods:



Disposal



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a) Using rubber carrying basket(s). These baskets are available in the Solvent Storage

Room.

b) Using a laboratory cart. Glass Bottles on carts should be in a secondary container,

e.g. a regular box or plastic tub to secure them on the cart.

4. Solvents are then transported via the service elevator to the Solvent Storage Room.

5. The bottles should be placed on the shelves in the Solvent Storage Room.

6. Each laboratory is responsible for maintaining their own inventory regarding what is

stored in the Solvent Storage Room, in the appropriate designated area.

6.1.2 Disposal of Used Solvents

1. Solvents should be disposed of in an appropriate glass container, affixed with a chemical

waste label. The label should be accurately and completely filled out:

2. Transport of glass containers should be done with a laboratory cart, or rubber carrying

basket(s). These baskets are available in the Solvent Storage Room.

3. Solvents are then transported via the service elevator to the Solvent and Chemical Waste

Room.

4. The bottles should be placed on the shelves in the Solvent and Chemical Waste Room, in

the appropriate designated area.

6.1.3 Disposal of Solid Material in Contact with Hazardous Chemicals

1. Place solid materials in contact with hazardous chemicals into a clear plastic bag.

2. Completely fill out and attach a chemical waste label (as illustrated above).

3. Transport the solid waste via the service elevator to the Solvent Storage Room.



Disposal



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4. The bag is then placed in the Solvent Storage Room, in the appropriate designated area.

7. Revision History

Rev # Date SOP

Section(s)

Revision Description Revised By

0 20-Mar-12 SOP PBSOP002 created. David Dubins (author)

1 05-Dec-12 6.1.1 • Item 1: Added the sentence

“Solvents should be transported in

their original packaging.”

Added the policy that Glass Bottles

on carts should be in a secondary

container, e.g. a regular box or

plastic tub to secure them on the

cart.

• Item 2: Added the policy that Glass

Bottles on carts should be in a

secondary container, e.g. a regular

box or plastic tub to secure them on

the cart.

David Dubins (reviser)

2 29-Jan-14 6.1.2

5.1.3

• Item 1: Location of disposal of

chemical solvents changed from

“Solvent Storage Room” to “Solvent

and Chemical Waste Room”.

• Item 2: Policy 5 removed (not

applicable to solvent disposal): “Each

laboratory is responsible for

maintaining their own inventory

regarding what is stored in the

Solvent Storage Room, in the

appropriate designated area.”

• Item 3: References to the “Solvent

Storage Room” have been changed

to the “Solvent and Chemical Waste

Room” in section 5.1.3.


~,. UNIVERSITY OF TORONTO",,", LESLIE DAN FACULTY OF PHARMACY

.1:tJ

Standard Operating Procedure Document ,

TItle: I Emergency Response and First AidSOP#: I PBSOPOO3 I Rev#: I 1

,'~ ," ",

Standard Operating Procedure"

Title: Emergency Response and First AidIssue Date: SEP 11 2011SOP#: PBSOPOO3Revision #: 1


All information contained in this document is the property of the Leslie Dan Faculty ofPharmacy, University of Toronto .

••Author of this Revision:David Dubins, Ph.D., B.Eng.:;7o£fety Committee

Date


Date

\ J ' 0 ~ ''2- () i?-)

Approved by:Peter J. Q'Brien, Ph.D.Professor EmeritusChair, Joint Health and Safety Committee

Date

Authorized by:Henry J. Mann, Pharm.D., FCCP,FCCM, FASHPDean and Professor

Date

Leslie Dan Faculty of Pharmacy. University of Toronto. 144 College Street, Toronto, Ontario, Canada M5S 3M2. Tel:416-978-2889. Fax: 416-978-8511

PBSOP003 Rev l.docx Page 1 of 6


Title: Emergency Response and First Aid



416-978-2889 • Fax: 416-978-8511


1. Scope

The scope of this SOP is to provide building-specific details regarding emergency response,

including fire alarms, and the management and administration of first aid.



following website:






2. Objective


building-specific procedures pertaining to the appropriate response to emergencies, specifically

fire alarms, and administration of first aid in the Leslie Dan Faculty of Pharmacy. The SOP outlines

the training available, as well as the logistics pertaining to emergency response.

The importance of the proper availability and administration of first aid is often overlooked, and is

paramount to minimizing impact of an accident on a person’s health. Having the proper

infrastructure available, in addition to faculty who are properly trained in first aid, is a key

component in ensuring and maintaining the health and safety in the Leslie Dan Faculty of

Pharmacy.

In addition, an organized and efficient response to a fire alarm is an important aspect of

emergency response. Building-specific policies and procedures are outlined in this SOP.

3. Background




Toronto. SOPs are now required by the Office of Environmental Health and Safety. This series of

SOPs are compliant with this requirement.





416-978-2889 • Fax: 416-978-8511


An efficient and appropriate emergency response, whether on an individual level (first aid), or on a

building-wide level (e.g. an organized response to a fire alarm), does not happen accidentally. It

hinges on the responsible and/or designated parties reacting in a pre-defined and organized way

in order to elicit the proper response. This SOP is designed to outline the current procedure for

first aid kit management, first aid administration, and fire alarm response at the Leslie Dan Faculty

of Pharmacy.

4. Definitions and Abbreviations The injured person refers to someone who is in need of first aid. The responder refers to a person

who is responding to an emergency, and in some cases may also be the injured person.





OEHS The Office of Environmental Health and Safety, University of Toronto


N/A Not Applicable

Rev. Revision

5. Policies 5.1.1 First Aid Kits

1. First Aid Guidelines are available on the OEHS website:

http://www.ehs.utoronto.ca/Assets/ehs+Digital+Assets/ehs3/First+Aid/First+Aid+Program

+2010.pdf

This guideline includes requirements of the minimum contents of a first aid kit.


occurs twice yearly in the Leslie Dan Faculty of Pharmacy. The administration of first aid,

including identifying the location of first aid kits, is a component of the safety training

course.

3. An accredited safety training course, “Standard First Aid”, is offered by the OEHS:

http://www.ehs.utoronto.ca/Training/training.htm

4. First aid kits are provided on each research floor of the Leslie Dan Faculty of Pharmacy

(floors 7-12). They are clearly marked, and mounted in a prominent location (usually the

alcoves in the back hallway).

5. The first aid kits are freely accessible to anyone inside or outside the building requiring

immediate first aid.

6. The first aid kit on each floor shall have 1 designated first aid person and 1 backup person

assigned. Both these people are required to have taken the OEHS Standard First Aid

training course.





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7. The contact information of the designated first aid person and backup will be clearly

marked on the first aid kit.

8. Each first aid kit shall contain an inventory list of its contents which shall comply with the

OEHS First Aid guidelines.

9. The inventory list shall be checked on a yearly basis by the Faculty Technician to ensure

that it is complete.

10. Principal Investigators can also opt to stock their individual laboratories with a first aid kit

and insure that it is current and complete.

5.1.2 Fire Prevention and Response

1. Fire prevention and emergency procedure guidelines are available on the UTFP website:

http://www.fs.utoronto.ca/utfp.htm


occurs twice yearly in the Leslie Dan Faculty of Pharmacy. The proper response to a fire,

including use of a fire extinguisher, is a component of the safety training course.

3. Fire extinguishers are provided on each floor of the building, and are clearly marked and

mounted in prominent locations.

4. Fire extinguishers are checked on a yearly basis by the OEHS.

6. Procedures

6.1.1 First Aid Administration

1. If first aid is required, the responder or injured person may access the floor first aid kit.

2. The responder or injured person may choose to access the kit independently. If additional

help is warranted, the designated first aid person for that floor may be contacted using

the information provided on the first aid kit.

3. The number for the Campus Emergency Centre for St. George Campus is 8-2222. If the

nature of the injury is not minor and medical attention needs to be sought, either 8-2222

is dialed from a university phone, 416-978-8222 from a land line, or 911 from any phone.

4. In the event that a first aid kit is used, the person using the first aid kit shall inform the

Faculty Technician so that the kit may be replenished.

5. If the nature of the injury is not minor, the responder (usually the designated first aid

person) shall complete an accident report form through the OEHS online system. If the

injured person is a student or visitor, the following form is used:

http://www.ehs.utoronto.ca/resources/wcbproc/Non_U_of_T.htm

If the injured person is a university employee, the following form is used:

http://www.ehs.utoronto.ca/resources/wcbproc/employee.htm

6.1.2 Fire Emergency Procedures

1. Upon discovery of the fire, the responder should first call 911, then pull the fire alarm, or

send a designate to perform the same. Then the Campus Police should be notified (416-

978-2222, or 8-2222 from a University phone).





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2. If the responder feels they can put out the fire safely with the use of one extinguisher, and

it is rated appropriately for the type of fire presented, they may use the fire extinguisher.

3. If the responder feels that they cannot put the fire out safely, they shall close the door as

they leave the affected room.

4. Elevators are not to be used during a building evacuation due to the fire alarm sounding.

5. Evacuation will reside in the designated waiting area outside the building, located

between the Leslie Dan Faculty of Pharmacy and the Faculty of Medicine Building.

6. People are not permitted to re-enter the building for any reason until authorized by the

Fire Officer.

6.1.3 Fire Emergency Procedures – Mobility Impaired

1. Details of fire emergency procedures are provided on the UTFP website:

http://www.fs.utoronto.ca/utfp/Mobility-Impaired.htm

2. If on ground floor, exit by normal means.

3. If above or below the ground floor:

• Telephone the Campus Police emergency (416)978-2222 from the nearest phone or

cellular phone.

• Tell the campus police dispatcher that the fire alarm in your building is sounding and you

are mobility impaired and cannot leave your floor area. If you smell smoke, or are in

immediate danger, inform the dispatcher.

• Provide your exact location - Floor and Room Number.

• Provide the phone number and extension you are calling from. Your information will be

relayed to emergency response personnel who are en route or on scene. Toronto Fire

Services will facilitate your evacuation if your safety is compromised.

• In the conditions at your location deteriorate (any increased danger or hazard), call the

dispatcher immediately with an update.





416-978-2889 • Fax: 416-978-8511


7. Revision History

Rev # Date SOP

Section(s)

Revision Description Revised By

0 20-Mar-12 SOP PBSOP003 created. David Dubins (author)

1 05-Sep-12 5.1.2 •••• Item 5 was removed: “Each floor

shall have a designated fire warden

to assist in the response to a fire or

fire alarm.”, as as EHS does not

approve of the use of Fire Wardens.


1 05-Sep-12 6.1.2 •••• Item 1 was modified: Upon

discovery of the fire, the responder

should first call 911, then pull the

fire alarm, or send a designate to

perform the same. Then the Campus

Police should be notified (416-978-

2222, or 8-2222 from a University

phone).

• Item 5 was removed: “Upon

hearing the alarm, the designated

fire warden on each floor will do a

sweep of each room to make sure

that everyone is aware of the alarm

and leaves the building via the stairs

and the nearest exit.” as as EHS does

not approve of the use of Fire

Wardens.


~,.i,\,.~ UNIVERSITY OF TORONTO~ LESLIE DAN FACULTY OF PHARMACY

Standard Operating Procedure DocumentTitle: I Autoclaving ProceduresSOP#: I PBSOP004 I Rev#: 10

Standard Operating ProcedureTitle: Autoclaving ProceduresIssue Date: APPR()\IFn t4AR 2 2 20l~SOP#: PBSOPOO4Revision #: 0



Author of this Revision:David Dubins, Ph,D., B.Eng.Member, Joint Health and Safety Committee

c2~Date


Date


Date

ph.~-M""-Authorized by:Henry J. Mann, Pharm.D., FCCP,FCCM, FASHPDean and Professor

-----,. ------------,---,---Leslie Dan Faculty of Pharmacy. University of Toronto. 144 College Street, Toronto, Ontario, Canada M5S 3M2. Tel:416-978-2889. Fax: 416-978-8511

PBSOP004 Rev O.docx Page 1of 3


Title: Autoclaving Procedures



416-978-2889 • Fax: 416-978-8511


1. Scope

The scope of this SOP is to provide building-specific details regarding the autoclaving of solids and

liquids in the Leslie Dan Faculty of Pharmacy.



following website:






There are two autoclave rooms in the Leslie Dan Faculty of Pharmacy: PB 1049, and PB 1149. This

SOP deals with building policies and procedures specific to these two rooms. The scope of this SOP

does not include instrument-specific operation instructions for operating the autoclaves.

2. Objective


building-specific procedures pertaining to autoclaving in the Leslie Dan Faculty of Pharmacy.

3. Background





requirement.








Title: Autoclaving Procedures



416-978-2889 • Fax: 416-978-8511



N/A Not Applicable

Rev. Revision

5. Policies

1. Autoclaving is discussed in the Laboratory Hazardous Waste Management and Disposal

Manual, available on the OEHS website:

http://www.ehs.utoronto.ca/resources/wmindex/wm5_1.htm


occurs twice yearly in the Leslie Dan Faculty of Pharmacy. Autoclaving is a component of

the safety training course.

3. Students or faculty wishing to use the autoclave equipment in PB 1049 and PB 1149 must

be authorized to do so, and shall be appropriately trained in the departmental safety

training course.

4. If a particular lab has concerns regarding whether or not an item may be autoclaved, the

Faculty Technician shall be consulted.

6. Procedures

6.1.1 Autoclaving

1. Equipment-specific procedures and guidelines pertaining to autoclaving are provided to

the students during the departmental safety training course.

2. Refer to hand-outs of this course for the proper autoclaving procedures.

3. Use of the autoclave room must be in accordance with the training provided.

7. Revision History


Description

Revised By


created.

David Dubins (author)

~iWl UNIVERSITY OF TORONTO" LESLIE DAN FACULTY OF PHARMACY

Standard Operating Procedure DocumentTitle: I CryogenicsSOP #: I PBSOPOOS I Rev#: 10

Standard Operating ProcedureTitle: CryogenicsIssue Date: APPp.()\/Fn ~1AR~ 2 2012sOP#: PBSOPOOSRevision #: 0



Author of this Revision:David Dubins, Ph.D., B.Eng.Me:Zt~omm;ttee

Date


Date


Date

If~0M~" _Authorized btHenry J. Mann, Pharm.D., FCCP,FCCM, FASHPDean and Professor

z t" JV\.A:-r r L - 12-Date

Leslie Dan Faculty of Pharmacy. University of Toronto. 144 College Street, Toronto, Ontario, Canada MSS 3M2. Tel:416-978-2889. Fax: 416-978-8511

PBSOPOOS Rev O.docx Page1 of 4


Title: Cryogenics



416-978-2889 • Fax: 416-978-8511


1. Scope

The scope of this SOP is to provide building-specific details regarding the safe transport and use of

cryogenic fluids in the Leslie Dan Faculty of Pharmacy.



following website:






2. Objective


building-specific procedures pertaining to cryogenic fluids (specifically liquid nitrogen) in the Leslie

Dan Faculty of Pharmacy.

3. Background





requirement.








N/A Not Applicable

Rev. Revision


Title: Cryogenics



416-978-2889 • Fax: 416-978-8511


5. Policies

1. Two resources are available concerning cryogens on the OEHS website:

Control Program for Liquid Cryogenic Transfer Facilities:

http://www.ehs.utoronto.ca/resources/manindex/cryogenic.htm

Standard for Inert Cryogenic Liquid Usage in the Laboratory (PDF file):

http://www.ehs.utoronto.ca/Assets/ehs+Digital+Assets/ehs3/Chemical+Safety/St

andard+for+Inert+Cryogen+Usage.pdf


occurs twice yearly in the Leslie Dan Faculty of Pharmacy. Cryogenics is a component of

the safety training course.

3. Students or faculty wishing to use cryogenic fluids must be authorized to do so, and shall

be appropriately trained in the departmental safety training course.

4. The Leslie Dan Faculty of Pharmacy does not have its own cryogenics facility.

5. Cryogenics are to be obtained by each lab in small quantities from the Medical Sciences

Building or on a contractual basis from other providers.

6. Procedures

6.1.1 Cryogenic Procedures

1. Equipment-specific procedures and guidelines pertaining to cryogenics are provided to the

students during the departmental safety training course.

2. Refer to hand-outs of this course for the proper cryogenics procedures.

3. Use of cryogenics must be in accordance with the training provided.

6.1.2 Cryogenic Fluid Transport

1. Any elevator in the building (passenger or freight) may be used to transport cryogenic

fluids, in quantities totaling less than 10 Litres.

2. Large quantities of cryogenic fluids must not be transported via elevator in the building

(>10 Litres).

3. Cryogenic fluids must be transported in vessels approved for their storage and transport.


Title: Cryogenics



416-978-2889 • Fax: 416-978-8511


7. Revision History


Description

Revised By


created.


~."""-~ UNIVERSITY OF TORONTO

" LESLIE DAN FACULTY OF PHARMACY

Standard Operating Procedure DocumentTitle: I Radioactive Material Handling and DisposalSOP#: I PBSOP006 I Rev#: 10

Standard Operating ProcedureTitle: Radioactive Material Handling and DisposalIssue Date: ADO Df'I\I C n M AD o I) I)n1l1

SOP#: PBSOPOO6 ~ ~~ t"· •.. L. •.•VI_

Revision #: 0

This is a controlled document, authored and maintained by the Joint Health and SafetyCommittee (JHSC)at the Leslie Dan faculty of Pharmacy, University of Toronto.


-Author of this Revision:David Dubins, Ph.D., B.Eng.M:2€i~committee

Date


Date


Date

-+(~1trvl~Authorized by:Henry J. Mann, Pharm.D., FCCP, FCCM, FASHPDean and Professor

22.., M.{l.J~ - JLDate

Leslie Dan Faculty of Pharmacy. University of Toronto. 144 College Street, Toronto, Ontario, Canada MSS 3M2. Tel:416-978-2889 • Fax: 416-978-8511



Title: Radioactive Material Handling and Disposal



416-978-2889 • Fax: 416-978-8511


1. Scope

The scope of this SOP is to provide building-specific details regarding the safe use and disposal of

radioactive materials in the Leslie Dan Faculty of Pharmacy.



following website:






2. Objective


building-specific procedures pertaining to the use and disposal of radioactive materials in the

Leslie Dan Faculty of Pharmacy.

3. Background





requirement.

Radiation protection is a specific area with unique hazards, and consequently additional

training is required for any person wishing to use radiolabels or radioactive materials in

their experiments.











416-978-2889 • Fax: 416-978-8511



N/A Not Applicable

Rev. Revision

5. Policies

1. Radiation safety policies and procedures are available on the OEHS website:

http://www.ehs.utoronto.ca/services/radiation.htm

2. The OEHS offers the following accredited radiation safety training courses:

• Radiation Protection Training

• Radiation Safety Online Refresher

• Sealed Sources Safety Online Training

• Sealed Sources Safety Online Training Refresher

3. The OEHS offers the following useful online resources:

• A Laboratory Work Specific Training Form

• EH&S Database Turorials

o Receiving Radioactive Material

o Entering Data in your Inventory Records

o Contamination survey

4. Radioactive Waste Management guidelines are available on the OEHS website:


5. Students or faculty wishing to use radioactive materials must be authorized to do so, and

shall be appropriately trained in the appropriate OEHS training course(s).

6. It is each laboratory’s own responsibility to ensure they are in compliance with OEHS

policies, which include (not inclusively) safe and appropriate handling, documentation,

keeping the appropriate logs, wearing the appropriate radiation tags, and conducting the

required swipe tests.

7. Radioactive waste is to be stored in the appropriate covered containers.

8. Radioactive waste is picked up from each lab individually.

6. Procedures

6.1.1 Radiation Procedures

1. Equipment-specific procedures and guidelines pertaining to the safe use and disposal of

radiation are provided to the students during the OEHS radiation protection training

course.

2. Refer to hand-outs of this course for the proper radiation procedures.

3. Use of radioactive materials must be in accordance with the training provided.





416-978-2889 • Fax: 416-978-8511


7. Revision History


Description

Revised By


created.


$0&.!Wl UNIVERSITY OF TORONTO11LESLIE DAN FACULTY OF PHARMACY~

Standard Operating Procedure DocumentTitle: I Biohazardous Material Handling and DisposalSOP #: I PBSOP007 I Rev#: 10

Standard Operating ProcedureTitle: Biohazardous Material Handling and DisposalIssue Date: APPROVFn MAR? ? ?01?SOP#: PBSOPOO7Revision #: 0



~c -MIif"-)~Author of this Revision:David Dubins, Ph.D., B.Eng.Member, Joint Health and Safety Committee

,,4~Date


Date

Approved by:Peter J. O'Brien, Ph.D.Professor EmeritusChair, Joint Health and Safety Committee

Date

;/~Q~-I-~----Authorized by:Henry J. Mann, Pharm.D., FCCP,FCCM, FASHPDean and Professor

Date

Leslie Dan Faculty of Pharmacy. University of Toronto. 144 College Street, Toronto, Ontario, Canada MSS3M2. Tel:416-978-2889 • Fax:416-978-8511



Title: Biohazardous Material Handling and Disposal



416-978-2889 • Fax: 416-978-8511


1. Scope

The scope of this SOP is to provide building-specific details regarding the safe use and disposal of

biohazardous materials in the Leslie Dan Faculty of Pharmacy.



following website:






2. Objective


building-specific procedures pertaining to the use and disposal of biohazardous materials in the


3. Background





requirement.

4. Definitions and Abbreviations Biological waste includes:

• liquids such as used cell culturing media, supernatant, blood or blood fractions (serum),

etc., which contain viable biological agents;

• materials considered pathological, including any part of the human body, tissues and

bodily fluids, but excluding fluids, extracted teeth, hair, nail clippings and the like that are

not infectious;

• any part of an animal infected [or suspected to be infected] with a communicable disease;





416-978-2889 • Fax: 416-978-8511


• non-sharp, solid laboratory waste (empty plastic cell culture flasks and petri dishes, empty

plastic tubes, gloves, wrappers, absorbent tissues, etc.) which may be, or is known to be,

contaminated with viable biological agents;

• all sharp and pointed items used in medical care, diagnosis, and research, including the

manipulation and care of laboratory animals, which should be considered potentially

infectious;

• laboratory glassware which is known or suspected to be contaminated with hazardous

biological agents.







N/A Not Applicable

Rev. Revision

5. Policies

1. The OEHS offers the following accredited Laboratory Biosafety Training course:

http://www.ehs.utoronto.ca/services/biosafety/training.htm

2. Biological Waste Management guidelines are available on the OEHS website:


3. Students or faculty wishing to use biohazardous materials must be authorized to do so,

and shall be appropriately trained in the appropriate OEHS training course(s).

4. It is each laboratory’s own responsibility to ensure they are in compliance with OEHS

policies, which include (not inclusively) safe and appropriate handling, documentation,

keeping the appropriate logs, wearing the appropriate protection, and following the

appropriate disposal procedures.

5. Biohazardous waste is to be stored in the appropriate covered yellow buckets bearing the

biohazardous symbol.

6. Biohazardous waste is picked up from each lab individually.

6. Procedures

6.1.1 Biosafety Procedures

1. Equipment-specific procedures and guidelines pertaining to the safe use and disposal of

biohazardous materials are provided to the students during the OEHS Laboratory

Biosafety Training course.

2. Refer to hand-outs of this course for the proper biosafety procedures.

3. Use of biohazardous materials must be in accordance with the training provided.





416-978-2889 • Fax: 416-978-8511


4. Biohazardous waste bins are collected weekly every Monday, from the building hallways

on research floors (7-12).

5. Biohazardous waste bins are stored inside individual laboratories appropriately authorized

to handle biohazardous materials (i.e. Level 2 and above laboratories).

6. Biohazardous waste bins from these laboratories are to be placed in the hallway on

Monday morning for collection.

7. Biohazardous waste bins are not to be placed in the hallway overnight, or over the

weekend.

7. Revision History


Description

Revised By

0 SOP PBSOP007

created.


~',UNIVERSITY OF TORONTO

,>". LESLlE DAN FACULTY OF PHARMACY">10

Standard Operating Procedure DocumentTItle: I Electrical SafetySOP #: I PBSOP008 I Rev#: 10

Standard Operating ProcedureTitle: Electrical SafetyIssue Date: APPROVFO t~AR? ? ?01?SOP#: PBSOPOO8Revision #: 0



Author of this Revision:David Dubins, Ph.D., B.Eng.Member, Joint Health and Safety Committee

62~

Date


Date


Date

Authorized by:Henry J. Mann, Pharm.D., FCCP,FCCM, FASHPDean and Professor

Date

Leslie Dan Faculty of Pharmacy. University of Toronto. 144 College Street, Toronto, Ontario, CanadaM5S 3M2. Tel:416-978-2889. Fax:416-978-8511

PBSOP008 Rev O.docx Page 1of 4


Title: Electrical Safety



416-978-2889 • Fax: 416-978-8511


1. Scope

The scope of this SOP is to provide building-specific details regarding the safety issues concerning

aging and/or faulty electronic laboratory instruments and equipment.



following website:






2. Objective

The objective of this SOP is to outline the appropriate policies, and the building-specific

procedures pertaining to electrical safety issues inherent in the use of electronic devices in the


3. Background





requirement.








N/A Not Applicable

Rev. Revision





416-978-2889 • Fax: 416-978-8511


CSA Canadian Standards Association

5. Policies

1. Electrical safety policies pertaining to the laboratory are available through the Laboratory

Fire Safety guidelines posted by Facilities and Services website:

http://www.fs.utoronto.ca/utfp/lab.htm

2. Electrical Safety Videos are available through the OEHS website:

http://www.ehs.utoronto.ca/resources/videos/videog1/videog4.htm

The following 5 minute videos are available:

• The Hazards of Electricity

• Electrical Safety: Safe Work Practices

• Electrical Safety: Qualified Employees

3. Safety training for graduate students is a degree requirement, and occurs twice yearly in

the Leslie Dan Faculty of Pharmacy. Electrical safety is a component of the safety training

course.

6. Procedures

6.1.1 Identification of Electrical Safety Hazards

1. Laboratory equipment should be periodically checked for the following symptoms:

• Fraying cords

• Improper grounding (i.e. no third/grounding prong)

• Aging electronics

• Smoking or sparking during operation

• Intermittent operation or shorting

2. It is the responsibility of the Principal Investigator and members of the laboratory to

identify, and service or replace faulty laboratory equipment.

3. Any concerns should be brought to the attention of the Faculty Technician.

6.1.2 A Circuit Breaker Engages

1. Laboratory equipment should never be plugged directly into an electrical outlet. A power

bar with a built-in CSA-approved circuit breaker will protect the equipment, and help

prevent a circuit breaker engaging.

2. If an electrical outlet is overloaded, or there is an electrical problem (e.g. a short) with a

specific piece of lab electrical equipment, the circuit breaker might engage and turn off

the power.

3. If the power is cut suddenly from a given piece of laboratory equipment, the user shall

unplug the device from the outlet and try to determine the source of the problem, which

may include:

• Too many instruments plugged into one outlet





416-978-2889 • Fax: 416-978-8511


• An electrical problem with the electronic device

• An electrical problem with the building (e.g. a power failure)

4. Another device that is known to be working is plugged into the outlet to determine

whether or not the outlet is live. If there is a power bar, locate and depress the circuit

breaker reset button.

5. If the outlet is not live (i.e. a working device does not power on), then the user shall take a

note of the exact room and location of the outlet, and call the University of Toronto Call

Centre (8-3000 from a University phone, or 416-978-3000 from any phone) to report the

incident. The University of Toronto Call Centre will dispatch an electronics technician

(during work hours) or an engineer (after office hours, in the event of an emergency) to

assess the incident and take the appropriate action.

6. If the outlet is live, then the laboratory equipment is faulty. A fuse may have blown, or

there may be a more impactful electrical problem. Consult the Faculty Technician for

further assistance.

7. Revision History


Description

Revised By


created.


~,~. ~ •UNl VERSITY OF TORONTO~ LESLlE [)/\N fACULTY 0" PHARMACY

r~""

Standard Operating Procedure DocumentTitle: I Laboratory Health and Safety Inspections

SOP #: I PBSOP009 I Rev#: 10

Standard Operating ProcedureTitle: Laboratory Health and Safety InspectionsIssue Date: APPROVF n I~AR? ? ?O1?SOP#: PBSOPOO9Revision #: 0

This is a controlled document, authored and maintained by the Joint Health and SafetyCommittee (JHSC)at the teslle Dan Faculty of Pharmacy, University of Toronto.


~O-Mo.r-' ~Author of this Revision:David Dubins, Ph.D., B.Eng.Member, Joint Health d Safety Committee

Date


Date

Approved by:Peter J. O'Brien, Ph.D.Professor EmeritusChair, Joint Health and Safety Committee

Date

Authorized by:Henry J. Mann, Pharm.D., FCCP, FCCM, FASHPDean and Professor

Date

Leslie Dan Faculty of Pharmacy. University of Toronto. 144 College Street, Toronto, Ontario, Canada M5S 3M2. Tel:416-978-2889 • Fax: 416-978-8511



Title: Laboratory Health and Safety Inspections



416-978-2889 • Fax: 416-978-8511


1. Scope

The scope of this SOP is to provide building-specific details regarding workplace safety inspections

(Laboratory Health and Safety Inspections) conducted by the Joint Health and Safety Committee

(JHSC) of the Leslie Dan Faculty of Pharmacy.


outlined by the Office of Environmental Health and Safety (OEHS), available online via the JHSC

Handbook:

http://www.ehs.utoronto.ca/resources/JHSCTemplates.htm



document, but rather the reader is referred to the link above, to the JHSC Handbook Templates,

and Policies and Procedures Listing Health and Safety Manual.

2. Objective

The objective of this SOP is to outline the appropriate resources, policies, and the building-specific

procedures pertaining to workplace inspections in the Leslie Dan Faculty of Pharmacy.

3. Background





requirement.

Laboratory inspections are an integral part of identifying, monitoring, and correcting safety issues

in the building laboratories (floors 7-12).












416-978-2889 • Fax: 416-978-8511


N/A Not Applicable

Rev. Revision

5. Policies

1. A Workplace Inspection Checklist for Laboratories is available on the OEHS website:

http://www.ehs.utoronto.ca/Assets/ehs+Digital+Assets/ehs3/JHSC/Templates/Inspectlab.

doc

2. The committee must establish a schedule of inspections when it is not practical to inspect

the entire workplace once a month, such as when the workplace is too large or complex.

At least part of the workplace is inspected monthly and the entire workplace is inspected

at least once a year. Workplace inspections are to be conducted in accordance with this

schedule. [7.7, pg8, JHSC Handbook 2007]

A Sample Schedule of Workplace Inspections is available on the OEHS website:

http://www.ehs.utoronto.ca/Assets/ehs+Digital+Assets/ehs3/JHSC/Templates/Inspection

Sch.doc

6. Procedures

6.1.1 Inspection Teams

1. Research floors (7-12 only) are allocated for inspection.

2. Each research floor is allocated an Inspection Team.

3. Each Inspection Team consists of at least 1 student, and at least one faculty member.

Inspection Teams may be larger, depending on the size of the research floor.

4. All members of the Inspection Team must be current members of the JHSC.

5. Members of inspector teams must not be involved in inspecting their own floor.

6.1.2 Performing the Laboratory Inspection

1. The exact time and date of inspection is not announced.

2. The Inspection Team enters the lab and announces the health and safety inspection.

3. Members of the lab being inspected shall make every effort to accommodate and

facilitate the inspection.

4. If a lab is closed during the planned inspection period, the Inspection Team must return

and conduct their inspection when there is at least one member of the laboratory present.

5. The Inspection Team will fill out an Inspection Checklist (“U of T Joint Health and Safety

Committee: Building Inspection Checklist”) for each Principal Investigator on the research

floor.

6. The Inspection Checklist is a working document, and is subject to modification, to suit the

needs and requirements of the Laboratory Health and Safety Inspection.





416-978-2889 • Fax: 416-978-8511


7. If a lab has more than one room on the research floor, the same Inspection Checklist may

be used. Notes or comments on the Inspection Checklist should be room specific.

8. Any findings of the Inspection Team are recorded on the Inspection Checklist.

9. Once the inspection is complete, the Inspection Checklist will be returned to the JHSC.

10. The JHSC will send a summary of findings to the Principal Investigator of the laboratory.

11. The laboratory will take corrective action to the inspection findings.

12. The laboratory will provide documentation to the JHSC that any safety issues have been

dealt with and are now compliant with OEHS and departmental policies.

7. Revision History


Description

Revised By


created.



Title: Emergency Procedures – Mercury Spills



416-978-2889 • Fax: 416-978-8511


1. Scope

The scope of this SOP is to provide building-specific details regarding the safety issues concerning

mercury spills in the Leslie L. Dan Faculty of Pharmacy building.



following website:






2. Objective

When mercury thermometers, mercury-containing UV lamps, lab equipment containing mercury

switches, or other vessels containing mercury are broken, they pose specific hazards that need to

be dealt with differently than regular spills. The objective of this SOP is to outline the appropriate

policies, and the building-specific procedures pertaining to mercury spills in the Leslie Dan Faculty

of Pharmacy.

3. Background





requirement.

4. Definitions and Abbreviations Abbreviations used in this document are defined in this section:





EPS Environmental Protection Services (Hazardous Materials)





416-978-2889 • Fax: 416-978-8511



N/A Not Applicable

Rev. Revision

5. Policies

1. Emergency procedures for mercury spills pertaining to the laboratory are available

through the OEHS website:

http://www.ehs.utoronto.ca/resources/manindex/eps/emrgmerc.htm

2. Safety training for graduate students is a degree requirement, and occurs twice yearly in

the Leslie Dan Faculty of Pharmacy. Mercury spill response is a component of the safety

training course.

3. If there is a specific hazard of a mercury spill in a laboratory, the Principal Investigator

should purchase a commercial mercury spill kit for the laboratory.

6. Procedures

6.1.1 Assessment of the Spill Magnitude

1. The first step in properly responding to a mercury spill is to qualitatively assess the

magnitude of mercury accidentally released.

2. It is the responsibility of the Principal Investigator and members of the laboratory to

identify and assess mercury spills in the laboratory, and respond immediately and

appropriately to prevent contamination and limit exposure.

3. A regular mercury thermometer typically contains less than 5 mL of mercury metal.

Mercury thermometers are typically out of circulation and have mostly been replaced with

alcohol thermometers. However, a number of mercury thermometers nonetheless are still

in the building. If a single mercury thermometer breaks releasing mercury metal, the spill

is considered to be small.

6.1.2 Responding to Large Mercury Spills

1. If a large spill is identified during office hours (8:30am – 4:30pm weekdays), the

Environmental Protection Services (EPS) division of the OEHS should be contacted directly,

at 416-978-7000 (or 8-7000 from a University of Toronto telephone).

2. If a large spill is identified outside of office hours, the University of Toronto Campus Police

should be contacted, at 416-978-2222.

3. The area containing the spill should be evacuated immediately, and sealed off until

assistance arrives.

4. The spill should be reported to the Principal Investigator or supervisor of the laboratory,

and to Environmental Health and Safety using the Accident/Incident/Occupational Disease

Report form, available through the OEHS website:

http://www.ehs.utoronto.ca/resources/wcbproc.htm





416-978-2889 • Fax: 416-978-8511


6.1.3 Responding to Small Mercury Spills

1. A small spill should be immediately cleaned up by the appropriate laboratory person who

has been appropriately safety trained.

• ATTEMPT TO PREVENT THE SPREAD OF MERCURY OUTSIDE OF THE CONTAMINATED AREA.

2. The mercury spill should be cleaned up immediately with an aspirator bulb, medicine

dropper, or a mercury sponge.

3. The mercury should then be placed in a sealed container. The device used to collect the

spilled mercury (along with any contaminated items, e.g. broken thermometer pieces,

gloves, suction bulbs) should be placed in the sealed container.

4. A vacuum cleaner should not be used to clean the spill, regardless of the size of spill.

5. The sealed container should be affixed with a chemical waste label. The label should be

accurately and completely filled out.

• The sealed container should not misrepresent the waste; i.e. do not use a

biowaste bag or pail, or anything with a Rad label.

6. Wash the surface with mercury neutralizing solution such as 20% sodium sulphide or

sodium thiosulphate.

7. If mercury has broken up into smaller globules, sprinkle with sulphur powder or

commercial product and leave for several hours before cleanup.

8. Transfer the sealed container to the Solvent and Chemical Waste Room in the penthouse

of the Leslie L. Dan Faculty of Pharmacy building.

9. The spill should be reported to the Principal Investigator or supervisor of the laboratory,

and to Environmental Health and Safety using the Accident/Incident/Occupational Disease

Report form, available through the OEHS website:

http://www.ehs.utoronto.ca/resources/wcbproc.htm

10. The OEHS can optionally be contacted to take measurements at the site of the spill, to

ensure there is no remaining mercury contamination. The OEHS requires a few days’

notice for this service.

7. Revision History


Description

Revised By

0 29-Jan-14 SOP PBSOP010

created.


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